Appendix IV: Test Your Knowledge! Answer Key

a. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

b. Always report on the basis of units included in the Healthcare Common Procedure Coding System code descriptor.

d. The code is reported for a service performed in addition to a primary service and is never reported as a stand-alone service.

b. The principal reason for the service provided on that date.

c. A diagnosis pointer in field 24E links the appropriate ICD-10-CM code(s) to services on each claim line.

b. Procedure-to-procedure edits pair codes that should not normally be billed to the same patient by the same physician or physicians of the same specialty and same group practice on the same date.

c. This edit was deleted before its effective date.

d. Modifier 24 (unrelated evaluation and management [E/M] service by the same physician or other qualified health care professional (QHP) during a postoperative period) is appended to the E/M code to designate that the service was unrelated to the prior procedure.

c. Modifier 54 is appended to the surgery procedure code when the physician does the procedure but another physician or QHP in another group practice accepts a transfer of care and provides postoperative management.

a. True. Current Procedural Terminology and Healthcare Common Procedure Coding System modifiers can be appended to procedure codes in either code set when appropriate.

d. All of the above. A patient’s risk of increased health care use or risk adjustment is calculated by using claims data for physician services, patient demographics, health plan type, duration of coverage, and prescription drugs.

a. Learning about Healthcare Effectiveness Data and Information Set (HEDIS) measures applicable to the patient panel and proactively providing related services is a physician activity that supports HEDIS measurement.

c. The patient’s experience with office staff can affect Consumer Assessment of Healthcare Providers and Systems survey results.

a. Health plans may count normal newborn care provided during the birth admission as 1 of 6 well-child visits before 15 months.

d. Each relative value unit component may be independently adjusted slightly upward or downward as a function of geographic area.

d. American Academy of Pediatrics chapter pediatric councils meet with payers to discuss pediatric issues.

b. A 2-digit place of service code is entered on the claim.

d. All of the above. Conducting internal audits or reviews informs practice policy and procedures, detects missed revenue, and prevents issues with payers and outside auditors through early detection of internal errors.

c. Assignment refers to the patients a payer includes on your panel roster.

a. The False Claims Act prohibits and establishes penalties for submitting claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.

d. Whenever a physician practice intends to enter a business arrangement that involves making referrals, legal counsel familiar with anti-kickback and physician self-referral laws should review the arrangement.

b. False. Compliance programs are required even for small practices, but they can be scalable.

d. All of the above. Compliant documentation must encompass what should be documented and safeguards from inaccuracies and potential noncompliant access to or disclosure of information.

c. Given the compressed timeline and dollars at stake, seeking legal advice is invaluable when a payer demands repayment based on atypical coding patterns.

d. Critical care (hourly) is not selected on the basis of medical decision-making (MDM) or total time.

c. Emergency department services are not selected on the basis of time.

d. Time of clinical staff who obtained history and vital signs is not included in a physician’s or qualified health care professional’s total time on the date of the encounter.

d. b and c. Any combination of at least 2 elements of MDM that support moderate MDM is required to report a code that requires moderate MDM.

a. Presence via real-time audiovisual technology is sufficient to support presence for the key portion of an evaluation and management service provided by a resident in a rural location.

d. Because the patient is seeing a physician of a different specialty (otolaryngology rather than primary care), the patient is new.

b. Review of the result of a test that was ordered between visits is included in the amount and/or complexity of data at the encounter during which the result is analyzed.

b. Follow-up evaluation and management (E/M) services initiated by the consultant or patient/family are reported as established patient visits based on the site of service (eg, established patient office visits).

a. To report services provided in an intermediate care facility for individuals with intellectual disabilities, a psychiatric residential treatment center, or a nursing facility, see codes in the Nursing Facility Services category.

a. Prolonged office E/M service (99417) is reported when the physician’s total time on the date of the encounter exceeds the minimum time of the primary service by at least 15 minutes. Clinical staff time and time spent on other dates is not included.

c. A newborn who is found to have ankyloglossia that requires release at the encounter is an example supporting an abnormal finding during a routine health examination.

a. Influenza immunization of an 18-year-old patient with physician counseling is reported with code 90460.

c. Administration of a COVID-19 vaccine is reported with codes 0001A–0112A.

b. Code 99402 is appropriate for reporting 23 to 37 minutes of preventive medicine counseling to an individual patient.

d. All of the above. The problem-oriented service must be separately identifiable in the documentation and significantly beyond the work of the preventive service, and modifier 25 is appended to the code for the problem-oriented service.

d. Codes 99441–99443 may be reported for the telephone evaluation and management (E/M) that is patient initiated and neither related to an E/M service within the prior 7 days nor occurring within a postoperative period.

d. All of the above. G2012 and G2252 are not limited to a specific asynchronous technology.

b. Online digital E/M services include the physician’s or other qualified health care professional’s cumulative time devoted to the patient’s care over 7 days whether the time is spent addressing a single problem or multiple different problems within the 7-day period.

a. The Centers for Medicare & Medicaid Services created code G2010 as a virtual check-in service allowing payment for evaluation of patient images and/or recorded video sent via digital technology.

c. When the reporting requirements are met, the requesting physician may report 99452 for time spent preparing for and participating in the consultative service.

d. The period of service for transitional care management begins on the date of discharge and continues for the next 29 days.

c. At least 20 minutes of clinical staff time spent in chronic care management activities must be documented to support code 99490.

d. To support principal care management, the complex chronic condition must be expected to last at least 3 months.

c. Principal care management and care plan oversight are never reported by a physician or qualified health care professional for the same patient in the same month.

b. Codes 99358 and 99359 are reported only when provided on a date other than the date of a face-to face evaluation and management service.

b. These services may be covered through a plan and provider network separate from other health care services.

c. A code for dependence is reported for substance abuse with dependence.

c. Psychiatric collaborative care management 99492–99494 are reported for activities of a behavioral health care manager working under physician supervision and in consultation with a psychiatric consultant.

a. Codes 96202 and 96203 are reported for behavior management/modification training provided to a multiple-family group of parent(s)/guardian(s)/caregiver(s).

b. False. The patient’s presence is not required for the service described by code 90846.

d. Interpretation and report is a professional component of a test.

a. Report code 36415 for all venipunctures not requiring the physician’s skills to perform the procedure. See 36416 for collection of a capillary blood specimen and 36400–36410 for venipuncture requiring a physician’s skill.

c. Report 87637 × 1 unit for performing the single test for SARS-CoV-2, influenza A and B viruses, and respiratory syncytial virus.

d. All of the above. Report injection of epinephrine in the office through an auto-injector with codes J0171 and 96372 and the National Drug Code for the auto-injector.

a. Code 96127 is not valued to include physician work.

d. Scope of practice is the term used to define the procedures, actions, and processes that are permitted for a licensed individual.

b. Qualified nonphysician healthcare professionals whose scope of practice does not include provision and independent reporting of E/M services may report assessment and management services.

a. Education and training for patient self-management are face-to-face services to an individual patient or a group of patients.

c. Modifier 33 is appropriately reported in addition to the code for medical nutrition counseling to indicate a preventive service.

d. A speech pathologist is a qualified nonphysician health care professional (QNHCP) as described in this chapter. Medical assistants are clinical staff and do not independently report services. Qualified health care professionals who may provide and independently report evaluation and management services are distinct from QNHCPs for coding purposes.

b. Local or topical anesthesia is included in the global surgical package.

c. Removal of foreign bodies from skin that do not require an incision is included in the work of an evaluation and management (E/M) service and not separately reported.

d. Report 30901 when nasal packing is placed to serve a hemostatic and/or tamponade role but not when placed in the short term to administer medication. Also, report 30901 for control of hemorrhage by cautery.

b. Report 51701 for urinary catheterization to collect a clean-catch urine specimen. An E/M service and urinalysis are separately reported services.

c. Therapeutic, prophylactic, or diagnostic injections of medication other than chemotherapy are reported with code 96372.

c. Of medical decision-making, 2 of 3 elements must be met to support the code selected for an emergency department service. Time is not a factor in code selection.

d. Code 99281 does not require the presence of a physician or qualified health care professional (QHP).

b. Seventh character D of an International Classification of Diseases, 10th Revision, Clinical Modification code indicates a subsequent encounter during the healing phase of an injury.

d. All of the above. Report modifier 54 if another physician or QHP will provide care during the postoperative period. Closed treatment of nasal fracture without manipulation is included in an evaluation and management service.

a. Report 99291 × 1 unit and 99292 × 1 unit for the continuous 80-minute episode of critical care service that extended beyond midnight.

d. 99463 is reported for the physician’s initial admission and discharge management services when provided on the same date (regardless of the date of the newborn’s birth).

a. 99465 (newborn resuscitation) is not reported in addition to 99464 (attendance at delivery).

d. The attending physician reports a category Z38 code (liveborn infant) and Z05.42 because the suspected infection was ruled out.

c. 99238 is reported for all discharge management services of 30 minutes or less except when admission and discharge management services are provided on the same date.

a. Subsequent visits following a consultation in the same admission are reported with codes 99231–99233.

a. When the physician has documented the total time spent on the date of the encounter, time may be used in code selection in lieu of medical decision-making (MDM).

c. Under Medicare split or shared guidelines, the individual who spent the greater portion of the combined time of service reports the service.

a. True. An outpatient evaluation and management (E/M) service provided on the same date may by separately reported, with modifier 25 appended to the outpatient code, in addition to an initial inpatient or observation E/M service.

b. When an attending physician provides both an initial face-to-face hospital service and discharge management at the same encounter, initial hospital or observation care (99221–99223) is reported.

d. When a physician spends 90 minutes providing initial hospital care with documentation of moderate MDM, code 99223 (≥75 minutes) is reported in conjunction with 1 unit of 99418 for the 15 minutes of prolonged service. 99418 is reported only when the primary E/M code is selected on the basis of time and is the highest code in the code category.

a. Initiation of selective head or total body hypothermia (99184) is reported separately when provided in conjunction with neonatal critical care (99468, 99469).

c. Split or shared policy applies when a physician and a qualified health care professional (QHP) of the same group practice provide critical care services.

b. Subsequent hospital inpatient or observation care (99231–99233) is reported for continuing care during the same admission.

d. Codes 99291 and 99292 (hourly critical care services) are reported for critical care services provided by physicians and QHPs other than the attending physician who reports daily codes.

c. Report 99479 (subsequent intensive care, infant weighing 1500–5000 grams) because subsequent intensive care is reported when the patient has previously received critical care services during the same admission.

c. Append modifier 78 when a return to the operating/procedure room is necessary for a related procedure or treatment of complications during the postoperative period.

d. Both a and c. Report a reduced service or discontinued procedure when instructed by Current Procedural Terminology or when the procedure was significantly less than the typical service.

b. The teaching physician must be immediately available to furnish services during the entire procedure but is not required to be personally present or personally perform a procedure that is not minor, complex, or high-risk. Endoscopy requires the physician’s personal presence during the procedure.

b. Code selection for left-sided heart catheterization for congenital heart defect is (93595) not based on the presence of normal or abnormal native connections.

a. Code 99024 is reported for manual breakdown of adhesions during the postoperative period because this work is included in the postoperative work of the procedure.

d. A synchronous telemedicine service is reported with modifier 95 appended to the code for the service provided.

c. Modifier 93 signifies that a service was provided via synchronous audio-only technology.

a. The location of the physician or qualified health care professional delivering a telemedicine service is the distant site.

c. Modifier FQ is used only when reporting services to manage mental health or substance use disorders. Modifier 93 is reported for any service designated as eligible in Current Procedural Terminology.

b. False. Code selection for telemedicine services is not limited to selection based on the time spent in direct communication with the patient and/or caregiver. The requirements of the code for the service provided must be met.

c. Physician review and interpretation of a patient’s self-collected data outside a face-to-face visit is reported with code 99091.

c. Code 94777 includes physician review and interpretation of the event data collected over a 30-day period and preparation of a report.

b. Code 99457 is used to report a physician’s time spent in a calendar month using the results of transmitted physiologic data to manage a patient’s treatment plan.

b. Patient-reported outcomes of therapy are an example of non-physiologic data that may be used in a treatment management service described by code 98980.

a. Remote physiologic monitoring treatment management services (99457, 99458) include time spent by clinical staff working under supervision by a physician or qualified health care professional.